VOL 48: DECEMBER • DÉCEMBRE 2002 Canadian Family Physician • Le Médecin de famille canadien 1893
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H
e was 4 months old, weighed less than 2 kg, and spent the better part of his life in an incuba- tor. His mother died at birth from symptoms associated with HIV infection, and the extended family that came to collect her body did not return for him. He was a semi- permanent fixture in the neo- natal ward—an AIDS orphan, unwanted, abandoned.He died shortly after our visit to Mosvold Hospital in Ingwavuma, Kwa-Zulu Natal South Africa, another statis-
tic of the AIDS epidemic currently ravaging many parts of Africa. Recent anonymous HIV testing of maternity patients in this area of South Africa has shown a one in three incidence of undiagnosed HIV.1 Current esti- mates of the rate of mother-to-child HIV transmission range between 16% and 28%, or roughly 1 in 4.2 Of the 1640 births annually at Mosvold Hospital, approximately 130 babies will have been vertically infected with HIV. The effects of these numbers of HIV-infected mothers and infants are both financial and emotional as well as both individual and communal, and they compromise the social fab- ric upon which the community once dwelled and prospered.
During the second year of my rural family medicine residency program at the University of British Columbia in Vancouver, I had the opportunity to travel to Ingwavuma to conduct a feasibility study for Mosvold Hospital, addressing the plausibility of implementing an antenatal HIV screening program.
In return for my work, I was to
gain more maternity training and experience in surgical obstetrics.
Fortunately, the most recent World AIDS Conference had just taken place in Durban, South Africa, and a plethora of information regarding vertical transmission and antenatal screening programs lay at my fin- gertips. The hospital itself had been managing AIDS and HIV–related dis- ease for years but had yet to imple- ment an HIV screening program.
Political denial of the role of HIV in AIDS has been the primary obstacle to developing and imple- menting an integrated antenatal HIV screening-treatment program in South Africa. Failure to acknowl- edge this fundamental association has prevented sufficient allocation of resources to purchase effective testing and treatment modalities.
Current testing methods involve transporting blood samples to the local tertiary laboratory facility capable of doing enzyme-linked immunosorbent assays—an obstacle that often results in lost samples;
delayed reporting, which affects
patient follow up; and ineffi- cient screening. Treatment is limited to managing peri- partum sexually transmit- ted diseases (STDs) and candidiasis infections where patient follow up actually occurs. Counselors have been trained and are avail- able for those identified as likely HIV-positive, but few patients take advantage of this support because the benefits are perceived as questionable in light of the stigmatization of being iden- tified as HIV-positive.
Barriers to implementing screening programs
Various other hospitals in the vicinity have attempted to implement ante- natal screening programs and have met with variable success. Manguzi Hospital in eastern South Africa had achieved a 100% screening rate for mothers. Their program included both group and individual counseling and provided some reasonable pre- natal follow up and basic treatments (antibiotics and antifungals for STDs or candidiasis infections) before delivery to help reduce vertical trans- mission. Unfortunately, only 10% of those screened would follow up on the results, so the screening process had little effect on preventing vertical transmission in this area.
Another hospital located south of Ingwavuma had also attempted a screening program but was able to persuade only 20% to 30% of mater- nity patients to undergo testing and even fewer to follow up on results.
Similar problems of lack of resources, inefficient testing and reporting
Letter from South Africa
Sojourn in South Africa
Wade Mitchell, MD
Making a difference and learning in the process:
Dr Wade Mitchell embraces staff members at the Mosvold Hospital in Ingwavuma, Kwa-Zulu Natal South Africa.
1894 Canadian Family Physician • Le Médecin de famille canadien VOL 48: DECEMBER • DÉCEMBRE 2002
letters
correspondance
VOL 48: DECEMBER • DÉCEMBRE 2002 Canadian Family Physician • Le Médecin de famille canadien 1895
letters
correspondance
procedures, and limited treatment capacity, in addition to the prevalent negative attitude toward HIV-positive people, all figured prominently in the failure of these programs.
A comprehensive literature search and a brief pilot survey regarding cul- tural beliefs and attitudes toward HIV helped to shed light on possible solu- tions for an effective antenatal screen- ing program. The literature review revealed the cost-effectiveness of both universal and targeted antenatal HIV screening programs (universal treat- ment being more economical in areas of high prevalence),3 the most effective treatment and testing strategies, and the psychosocial components essen- tial to its implementation. Numerous examples of successful programs implemented in the developing world showed that such programs were not only necessary but also entirely fea- sible even in low-resource countries.4 Fortunately, numerous affordable and simple treatment strate-
gies, which do not require use of antiretroviral drugs to help reduce vertical transmission, are readily available in many of these communities. Studies sug- gesting that most verti- cal transmissions actually
occur via cervico-vaginal secretions around delivery5 support use of modal- ities, such as elective cesarean sections (providing the mother’s health can bear the stress of such a procedure),6 chlorhexidine douches, and treatment of STDs or candidiasis infections that occur peripartum.7
Breastfeeding, especially mixed feeding (formula and breastfeed- ing), also contributes strongly to vertical transmission.8 Either exclu- sive breastfeeding for at least 4 to 6 months or simply providing formula for HIV-infected mothers during the first 6 to 12 months and foregoing breastfeeding actually improves mor- bidity and mortality. Mothers with HIV benefit because their bodies can forego the stresses of milk produc- tion. Formula feeding, however, is fraught with difficulty in developing countries because of poor hygienic conditions. If antiretrovirals, spe- cifically nevirapine, were to be made
available, a simple two-dose program, one to the mother during labour and one to the infant upon delivery, could be cost-effective and efficacious for reducing vertical transmission9 dur- ing vaginal delivery. Rapid testing kits with near-perfect sensitivity and specificity currently exist and would improve screening and follow up.10
Finally, improved community edu- cation and counseling support with stringent confidentiality protocols are essential to creating a successful program.11 The pilot survey of cul- tural attitudes and beliefs illustrated a fairly well informed populace regarding the cause, symptoms, and mechanisms of HIV transmission as well as, and more importantly, a definitive fear of being labeled HIV- positive. If no treatment were avail- able for mothers or infants, what is the point of testing?
Government acknowledgment crucial to success Successful implemen- tation of antenatal HIV screening-treatment pro- grams for communities such as Ingwavuma will depend first and foremost
Letter from South Africa
1894 Canadian Family Physician • Le Médecin de famille canadien VOL 48: DECEMBER • DÉCEMBRE 2002
letters
correspondance
VOL 48: DECEMBER • DÉCEMBRE 2002 Canadian Family Physician • Le Médecin de famille canadien 1895
letters
correspondance
on government acknowledgment of the role of HIV in AIDS. Ceding this essential relationship will mandate allocation of national and international resources to provide the essential components for imple- menting an integrated antenatal HIV screening-treatment program.
Although a targeted treatment pro- gram using rapid testing would permit improved surveillance, support, integrated breastfeeding counseling, and less likelihood of adverse reactions or side effects from universal treatment protocols with single-dose nevirapine, the cost-effectiveness and efficacy of the universal treatment would help avoid problems with testing and the associ- ated stigmatization of those found to be HIV positive. Without access to antiretroviral therapies, implement- ing antenatal screening-treatment programs will depend on targeted protocols so that other simple, avail- able treatments, counseling, and fol- low up can occur.
To be successful, it will be essen- tial to procure rapid-testing kits and conduct group and individual pre- test counseling and immediate post- test counseling to permit adequate follow up and implementation of individual support and treatment protocols, which might include selenium supplementation, peripar- tum STD and candidiasis infection treatment, possible elective cesar- ean section, and counseling about exclusive breastfeeding or, if possi- ble, hygienic use of exclusive infant formula.
Aside from the research and maternity work, I also helped out with various antenatal, emergency, and general health clinics both at the hos- pital and in nearby communities that required an often hair-raising, fixed- wing flight into and out of the clinics.
My newlywed wife taught basic sci- ences to grades 6 to 9 students at the local elementary school. When she asked them about any recent wed- dings in their community, she was struck by their answer that fewer weddings than funerals took place because of the HIV and AIDS epi- demic. It seemed that every second weekend a funeral was being held in the local church, with beautiful but sombre hymns emanating through- out the hospital compound.
On the lighter side . . .
We managed to explore a fair bit of northeastern South Africa with some field trips to local game parks and weekend excursions. We also paid brief visits to Swaziland and Mozambique. It was amazing how a mere 2 months could fly by so quickly, but alas we made our way back to British Columbia to finish my residency and pursue other avenues.
As with our previous experiences working in low-resources communi- ties, we were again touched by the human aspect of the experience. Our desire to devote at least some part of our future toward similar work and to expose our children to the breadth of understanding that comes with these
adventures has once again been renewed. I am currently undertak- ing a third year of training in obstet- rics and surgery for further rural or remote as well as international work, as it is with these skills that I feel I can really make a difference and learn a great deal in the process.
Competing interests
Dr Mitchell was funded through an interna- tional health fellowship from the Society of Obstetricians and Gynaecologists of Canada.
Dr Mitchell is a family physician currently completing an extra year of training in obstetrics and general sur- gery in Surrey, BC.
References
1. Fredriksson J. National HIV and Syphilis Sero-prevalence Survey of Women Attending Public Antenatal Clinics in South Africa—2000, Summary Report. South Africa: South Africa HIV/AIDS Statistics 1999-2001. Available from: http://
www.avert.org/safricastats.htm. Accessed 2002 October 29.
2. Mwanyumba F, Wiktor S. Mother to child transmission. Results from African studies [oral presentation]. XIII International AIDS Conference; 2000 July 9-14; Durban, South Africa. Conference Session Report available from: http://www.uct.ac.za/depts/chu/
mch15f.rtf. Accessed 2002 Oct 31.
3. Marseille E, Kahn JG, Mmiro F, Guay L, Musoke P, Fowler MG, et al. Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa. Lancet 1999;354(9181):803-9.
4. Soderlund N, Zwi K, Kinghorn A, Gray G. Prevention of vertical transmission of HIV: analysis of cost effectiveness of options avail- able in South Africa. BMJ 1999;318:1650-6.
5. Mwanyumba F, Gaillard P, Verhofstede C, Claeys P, Chohan V, Mandaliya K, et al. Exposure to HIV-1 during delivery and mother-to-child transmission. AIDS 2000;14(15):2341-8.
6. Fiscus S, Adimora A, Schoenbach V, Tristram D, Lim W, Mckinney R, et al. Elective C-section may provide additional benefit in con- junction with maternal combination antiretroviral therapy to reduce perinatal HIV transmission [abstract]. In: XIII International AIDS Conference. 2000. Abstract WePpCl1388. Available at:
www.iac2000.org. Accessed 2002 October 29.
7. McClelland R, Wang C, Mandaliya K, Overbaugh J, Reiner M, Ndyinya-Achola J, et al. Treatment of cervicitis is associated with decreased cervical shedding of HIV-1 DNA [abstract]. In: XIII International AIDS Conference. 2000. Abstract MoOrA231: p. 11.
8. Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha A, et al. Effect of breastfeeding and formula feed- ing on transmission of HIV-1: a randomized clinical trial. JAMA 2000;283(9):1167-74.
9. McIntyre J, The SAINT Study Team, Evaluation of safety of two simple regimens for prevention of mother to child transmis- sion (MTCT) of HIV infection ‘Nevaripine(NVP) vs lamivudine (3TC)+ zidovudine(ZDV)’ used in a randomized clinical trial (The SAINT study) [abstract]. In: XIII International AIDS Conference.
2000. Abstract TuOrB356: p. 329. Available at: www.iac2000.org.
Accessed 2002 October 29.
10. Koblavi-Deme S, Maurice C, Yavo D, Sibailly TS, N’guessan K, Kamelan-Tano Y, et al. Sensitivity and specificity of human immunodeficiency virus rapid serologic assays and testing algorithms in an antenatal clinic in Abidjan, Ivory Coast. J Clin Microbiol 2001;39(5):1808-12.
11. Garcia PJ, Velasquez C, Segura P, Sanchez J. Program for the Prevention of Vertical Transmission: The Peruvian Experience [abstract]. In: XIII International AIDS Conference. 2000.
Abstract ThPeC5314. Available at www.iac2000.org. Accessed 2002 October 29.
